Sutton Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to, people’s safe care and treatment and good governance at the service.We have asked the provider to take action to improve the service.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Safety concerns raised by staff were not consistently listened to or acted upon. All staff spoken with told us they had raised concerns about insufficient staffing and the impact this had on people’s safety. The registered manager and provider did not take effective action to address these concerns. The provider did not ensure all safety incidents were appropriately reported or reviewed, which meant risks were not effectively identified or mitigated. As a result, lessons were not learned, and opportunities to reduce the likelihood of repeated incidents were missed. For example, the provider did not analyse whether staffing deployment contributed to people experiencing repeated falls or consider whether these incidents could have been avoided through changes to staffing levels, supervision, or support. A relative told us, “Yesterday [staff] told me that my relative was hunched over and fallen. The paramedics stitched their head. This fall was unwitnessed; it is a busy environment; They haven’t said what they will do to prevent this happening again.”

When people experienced behaviour of distress, these incidents were not always recorded. This meant the provider could not identify patterns, understand triggers, or implement strategies to reduce distress and associated risks. This meant there was not a learning culture and people were at risk of avoidable harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The registered manager told us people’s needs were assessed prior to admission; this was not consistently reflected in care planning. Some people had inaccurate or absent care plans and risk assessments to guide staff in providing safe care. For example, a person diagnosed with epilepsy did not have a care plan or risk assessment in place. This meant staff did not have the information they needed to understand seizure risks or how to respond safely in the event of an emergency. The provider did not always ensure continuity of care, including when people experienced changes in their needs and the management team had not always made timely referrals to healthcare professionals when specialist advice was required. For example, when a person’s mobility deteriorated, there was no referral to a relevant health professional to assess the change, identify the cause, or provide guidance on how to support the person safely. This placed the person at increased risk of harm. Due to the lack of inaccurate written guidance, there was a risk that incorrect information could be shared about people’s needs when moving between services. This meant continuity of care could not be assured and there was a risk that care would not be provided safely during transitions.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Whilst there was a safeguarding policy in place and staff had completed training. Concerns about people’s safety were not always raised promptly or appropriately. For example, not all safeguarding incidents had been reported to the local authority safeguarding team.

During our visit, we observed verbal abuse between people using the service. Staff and the registered manager did not identify these incidents as abuse, demonstrating a lack of understanding of safeguarding responsibilities and risks. Furthermore, repeated incidents of falls were not effectively managed, and no consistent action had been taken to reduce the risk of reoccurrence. This meant people were at continued risk of harm.

Some people at the service were subject to a Deprivation of Liberty Safeguard (DoLs), this is where the person cannot make decisions about their care and treatment. So restrictive care arrangements are legally authorised in the person’s best interest. We found conditions attached to authorisations were not always complied with or detailed in people’s care records.

The provider did not work well with people to understand and manage risks. Staff could not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People with health conditions such as diabetes did not have individualised care plans or risk assessments in place to guide staff on how to manage their health needs or identify signs and symptoms that required timely escalation to healthcare professionals.

We observed staff using equipment to support a person with transfers; however, there was no mobility assessment, or risk assessment in place to demonstrate that the equipment was safe and appropriate for the person’s needs. This increased the risk of unsafe moving and handling practices. Furthermore, when people showed signs of distress, there was not always detailed care plans in place to guide staff on how to recognise triggers or provide appropriate support to reduce distress. This meant staff did not have the information they needed to respond consistently or safely. People, or their relatives where appropriate, were not always involved in risk assessments or care plans. On relative told us, “I have not seen the Care Plan and would like to see it.” This meant there was a risk of people not always having their risks managed appropriately.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to maintain the building and equipment safely.

Regular servicing contracts were in place, including electrical safety checks and fire risk assessments. Where risks were identified, plans were developed to address them, and necessary improvements were made. This meant there were processes in place to ensure the building was safe.

Routine checks were carried out to maintain a safe environment, including monitoring fire safety and water temperatures. During the inspection, we found some doors that should have been locked were unlocked; however, immediate action was taken to rectify this.

The provider did not ensure there were enough qualified, skilled, and experienced staff to meet people’s needs safely. Staff did not always receive effective support, supervision, or development, and teamwork was not consistently coordinated to provide safe care tailored to individuals.

There were insufficient staffing numbers on each shift. The registered manager told us, a staffing calculation tool was used and reviewed monthly; however, we found it was not completed accurately. It did not allocate sufficient time to meet people’s assessed care needs or manage risks and did not consider the layout of the building. For example, one person’s care plan showed they required to be repositioned every 2 hours, however there was no staffing time allocated for this care. This meant people were at risk of harm or further skin deterioration.

All staff, professionals and most of the relatives we spoke to told us there was insufficient staffing levels. One relative told us, “On a few occasions in the evenings there are no staff around. I have helped to give residents a drink and picked things up for them when there is no one around. This is because of lack of staff.” A staff member told us, “Staffing levels are my main concern and [management] keep saying needs analysis is showing we have enough staff, however these are residents living with dementia and their needs change, 10 people to support with eating, 2/4 people cared for in bed, you cannot spilt yourself between everyone, I want to do my role good and this is not possible. People are at risk, and the layout doesn’t help, people like to wander, and we cannot supervise everyone to keep them safe.”

Staff had not completed all required training, including training to support people with individual health conditions to ensure they had the skills and knowledge needed to safely support people with these conditions. This meant that people may not receive safe or appropriate care and placed them at risk of harm. Although staff were supported to have one-to-one supervision sessions, these were not always effective. Staff told us supervision was not always meaningful because they did not feel their concerns were consistently listened to or that they were adequately supported to address risks in people’s care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had an infection prevention and control (IPC) policy in line with current good practice standards. Sutton Lodge was well maintained, appeared clean and there were no malodours. We observed there was personal protective equipment (PPE) available such as gloves and aprons. This meant the risk of infection to people at the home was reduced. A relative told us, “Everywhere is clean and tidy and well presented.” Relatives told us they felt their family members personal hygiene was maintained. One relative told us, “Our relative is clean and does not smell.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We reviewed medication administration records (MAR) for a sample of residents and found that people were not always receiving their medicines including time sensitive medicines on time. We found that medicines being declined by residents or omitted by staff were not always being escalated for review by a clinical professional.

We found that there were no robust checks being undertaken of resident’s prescriptions to ensure they matched the supplied medicine and the Electronic Medicines Administration Record(EMAR).We found incorrect prescriptions on the EMAR system, that included items that did not match the prescription and duplicated medicines.

Staff did not always store medicines securely, or at the correct temperature. However, the service has introduced a new process following the assessment to ensure temperature monitoring is more robust. Two members of staff carried out regular controlled drug checks, which are medicines at higher risk of misuse. However, an entry that highlighted a stock discrepancy was not identified and investigated appropriately.

Medicine protocols and care plans lacked personal information to guide and support staff to meet resident's needs. Protocols for ‘as and when needed’ (PRN) medicines were in place, however we found they did not include information to guide staff on how to determine the correct dose when the prescribed dose was variable.

Staff treated residents with kindness when they gave medicines. Staff received medicines training and were assessed as competent to provide medicines support.

We reviewed a sample of reported medicines incidents. The records described what happened and what actions staff took. However, they did not always record what learning came from the incident or whether this was shared. Staff told us that learning was shared in team meetings, but this was not always documented. Medicine’s audits, including patient medication audits and medicines stock audits were carried out. However, the oversight process in place did not always identify issues that appeared in the audits. For example, staff completed temperature monitoring forms incorrectly, but the oversight check did not identify these errors.